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CERTIFICATION <br /> The Applicant, Weld County Public Works (print applicant/company name), <br /> by Jay McDonald (print representative's name), as Director of Public Works (print <br /> representative's title), does hereby certify that (structure owner) shall <br /> be compensated for any damage from the proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br /> Permit Application for Peters 313 Pit (operation name), <br /> File Number M--2015_045 . <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and <br /> the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations. <br /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant Weld County Representative Name Jay McDonal <br /> Date q q ���% Title Director of Public Works <br /> STATE OF Colorado ) <br /> ss. <br /> COUNTY OF Weld ) <br /> The foregoing was acknowledged before me this day of , 20 i by <br /> Jay McDonald as Director of Public Works <br /> ZLc��My Commission Expires: 12_- ,ZGZ1 <br /> Not ublic <br /> JacqusliT -Harrow <br /> STATE OF <br /> �� 1 <br /> SAt10UST 1 ZOQ1 <br />